A virtual issue highlighting eating disorders in people of black/African and Indigenous heritage

Predictors of Outpatient and Inpatient Service Utilization Among Publicly-Insured Youth With Eating Disorders

INTRODUCTION

Although eating disorders (EDs) affect youth from all socioeconomic backgrounds, little is known about the treatment experiences of under-resourced youth with EDs. To address this gap, we examined patterns of outpatient and inpatient service utilization among publicly-insured youth with EDs in California and potential disparities for youth with additional marginalized identities.

METHOD

Participants were identified from the full sample of California Medicaid/Medi-Cal beneficiaries aged 7-18 with ≥ 1 service episode between January 1, 2014 and December 31, 2016. Claims data were extracted for youth with a full year of claims after the first known ED diagnosis (N = 3311) to analyze outpatient mental health, outpatient medical/physical, inpatient mental health, and inpatient medical/physical service use across ED diagnosis and demographic characteristics (sex, age, race/ethnicity, and preferred language).

RESULTS

Outpatient individual and family therapy service utilization was low across ED diagnoses (4-7 individual therapy sessions and ≈5 family therapy sessions annually). Conversely, hospitalization rates were high, particularly among youth with anorexia nervosa (27.8%) and bulimia nervosa (30.0%). Youth with other specified feeding or ED had high medical service utilization, with more days of outpatient medical care and greater odds of medical hospitalization than youth with all other diagnoses. Latinx youth, Black youth, and boys tended to receive fewer services after accounting for diagnosis, with disparities particularly pronounced for Latinx youth.

CONCLUSIONS

Publicly-insured youth with EDs in California experience high hospitalization rates but receive limited outpatient therapy. Additional research is needed to identify possible unmet needs and factors contributing to treatment disparities among these youth.

Improving adult inpatient eating disorder treatment: perspectives of a sample of individuals in Canada with lived experience

BACKGROUND

Eating disorders (EDs) are increasingly common, affecting over one million individuals in Canada. Canadian adults (i.e., age 18+) requiring medical stabilization for their eating disorder (ED) may be referred to adult inpatient (IP) ED treatment for care. Recent Canadian publications have brought attention to the need for improved approaches to Canadian ED treatment; urging researchers to seek perspectives of people with lived experience to determine how to best do so. This study explored the perspectives of a sample of individuals in Canada with lived experience to identify recommendations for improvement of adult IP ED treatment programs and processes.

METHODS

Employing a transformative philosophical view and feminist standpoint theory, this study utilizes a qualitative hermeneutic phenomenological approach to fulfill the objectives. Eleven participants with lived adult IP ED treatment experiences from across Canada were interviewed individually, to discuss their experiences and recommendations regarding referral, transitions into and out of care, and treatment itself using an online video conference platform. Data were analyzed using interpretative phenomenological analysis. A comprehensive list of recommendations was drafted and brought back to participants for feedback. The feedback was implemented to create the final list of recommendations.

RESULTS

Several limitations of referral, transitions, and treatment, facilitated and exacerbated by stigma at individual and societal levels, were identified by participants. These included guilt and shame upon referral, lack of respect and trust from healthcare providers during transitions, and lack of consideration of social determinants of health during treatment. Participant-informed recommendations, which can be categorized as interim support, individualized care, dignified treatment, resources, and stigma, were identified to ameliorate the experiences of those in Canada with EDs while also combatting stigma.

CONCLUSIONS

Adult IP ED treatment in Canada is in urgent need of significant change to meet the needs of those requiring care and to address harmful stigma. Implementing participant-informed recommendations may aid in achieving this goal. The meaningful inclusion of those with lived experience, particularly marginalized populations, will be paramount to the development of an approach to adult IP ED treatment that properly serves individuals in Canada who need it.

The Relationship Between Racial Attitudes and Disordered Eating Behaviors in Black Men and Black Women

OBJECTIVE

Black individuals remain underrepresented in disordered eating research, despite evidence that both Black men and women present with disordered eating behaviors. Culturally-informed theoretical frameworks suggest that these behaviors may be linked to race-related sociocultural experiences, such as aspects of racial identity. While studies have focused on racial identity commitment, the association between attitudes toward one's racial identity and disordered eating remains underexplored. The present study examines whether positive attitudes toward one's Blackness and Black culture are associated with disordered eating.

METHOD

In a cross-sectional online sample of Black men and women (N = 458), we measured self-reported attitudes toward Blackness (i.e., centrality and private regard) and disordered eating behaviors (i.e., purging, binge eating, excessive exercise, and drive for thinness).

RESULTS

In pre-registered linear regression models, private regard was negatively associated with purging and binge eating. Across all models, centrality was not associated with disordered eating. On average, Black women reported greater drive for thinness whereas Black men reported higher excessive exercise scores.

DISCUSSION

This is the first study to demonstrate associations between racial attitudes and disordered eating among Black men and women. Our findings affirm unique correlates of disordered eating among Black people and suggest that positive attitudes toward one's Blackness and Black culture may be a protective factor against the development of disordered eating.

Disordered Eating/Eating Disorders in Adolescents

The coronavirus disease 2019 pandemic was as tressful time for adolescents, with increased isolation, loss of routines, and changes in access to medical care. In this setting, the medical system saw a significant rise in the number of adolescents seeking care for eating disorders, as well as increased severity of patient presentation. Telehealth treatment for eating disorders was a unique shift during the pandemic, with some benefits but not universally positive experiences among patients, families and providers.

General Psychiatric Management for Adolescents With Borderline Personality Disorder and Eating Disorders

Borderline personality disorder and eating disorders frequently co-occur among youths. These disorders emerge in adolescence, during the critical developmental period of building an independent sense of self and the capacity to relate to one's community. Because of core differences in the development and psychopathology of borderline personality disorder and eating disorders, adjustments are required when treating these disorders when they co-occur. Few established treatment approaches can address these disorders simultaneously. Evidence-based psychotherapies for borderline personality disorder, such as dialectical behavior therapy and mentalization-based treatment, have been adapted to accommodate the shared vulnerabilities and features of the two disorders. However, these approaches are specialized, intensive, and lengthy and are therefore poorly suited to implementation in general psychiatric or primary health care, where most frontline mental health care is provided. Generalist approaches can fill this public health gap, guiding nonspecialists in structuring informed clinical management for these impairing and sometimes fatal disorders. In this overview, the authors describe the adjustment of good (or general) psychiatric management (GPM) for adolescents with borderline personality disorder to incorporate the prevailing best practices for eating disorder treatment. The adjusted treatment relies on interventions most clinicians already use (diagnostic disclosure, psychoeducation, focusing on life outside treatment, managing patients' self-destructive behaviors, and conservative psychopharmacology with active management of comorbid conditions). Limitations of the adjusted treatment, as well as guidelines for referring patients to specialized and general medical treatments and for returning them to primary generalist psychiatric care, are discussed.

Insecure attachment and eating disorder symptoms: Intolerance of uncertainty and emotion regulation as mediators

OBJECTIVE

Literature on eating disorder (ED) symptoms of Black, Indigenous, and People of Color (BIPOC) group is extremely scarce. This study aimed to understand the mechanisms underlying the associations between insecure attachment and ED symptoms and examine whether these mechanisms differed between White and BIPOC groups.

METHOD

The study investigated direct and indirect relationship between attachment anxiety/avoidance and ED symptoms via intolerance of uncertainty (IU) and emotion regulation strategies of suppression and reappraisal. Further, we examined whether the proposed mechanisms equally represented White versus BIPOC using Multigroup Structural Equation Model (MG-SEM). A total of 1227 college students (48.50% BIPOC and 51.50% White) completed research questionnaires.

RESULTS

Results showed that IU and suppression mediated the relations between insecure attachment and ED symptoms for both White and BIPOC groups. Uniquely, reappraisal mediated the relations between insecure attachment and ED symptoms for the White group, but not for the BIPOC group.

DISCUSSION

The implications of the findings for culturally informed practice are discussed, including targeting increasing tolerability of uncertainties and improving emotion regulation to mitigate ED symptoms for those with insecure attachment.

Integrating context in the examination of pubertal timing effects on disordered eating among Black and Latinx girls

Earlier pubertal onset has been associated with increased disordered eating symptoms in cisgender girls. Although this finding has been replicated across studies of disordered eating, most studies have focused on white samples. The lack of studies is surprising given that early pubertal timing may impact disordered eating risk in Black and Latinx girls differently due to trends of earlier pubertal onset in these groups and increased stressors related to interpersonal and structural racism and economic marginalization. Current methods of examining pubertal timing among Black and Latinx girls may also not fully capture their experience. Contextual factors (e.g., neighborhood and school racial/ethnic composition) may influence how minoritized girls both perceive and are affected by their pubertal timing. Moreover, factors such as ethnic-racial identity development and experiences of discrimination may be important mechanisms explaining the association between pubertal timing and disordered eating risk. This paper aims to provide a brief overview of studies examining pubertal timing and disordered eating risk among Black and Latinx girls in the US and to discuss recommendations for future research that integrate contextual factors in the examination of pubertal timing and its effects. PUBLIC SIGNIFICANCE: Early pubertal timing has been associated with increased risk of disordered eating symptoms among cisgender girls; however, studies have been limited due to the use of predominantly white samples. The article provides a brief overview of findings related to pubertal timing effects among Black and Latinx girls, discusses considerations for the measurement of pubertal timing, and highlights the need for inclusion of contextual factors in future research.

Protocol for a scoping review to identify research reporting on eating disorders in minority ethnic populations in the UK, Canada, Australia and New Zealand

INTRODUCTION

Eating disorders (EDs) are common, severe and often life-threatening psychiatric conditions. Notwithstanding stereotypes, EDs affect individuals from all racial and ethnic backgrounds. However, despite similar and in some cases increased prevalence of disordered eating and EDs among minority ethnic groups, there appear to be disparities when it comes to ED diagnosis and treatment. To date, most of the existing literature exploring disordered eating and EDs among minority ethnic groups has been conducted in the USA. The present scoping review aims to examine the extent, range and nature of research activity into disordered eating and EDs in the UK, Canada, Australia and New Zealand providing a comprehensive overview of the existing literature. A special focus will be placed on studies exploring prevalence, access to care and treatment experiences.

METHODS AND ANALYSIS

The scoping review framework first outlined by Arksey and O'Malley and improved on by Levac et al was used to guide the development of this scoping review protocol. A detailed systematic search of relevant databases (Medline, EMBASE, PsycINFO, CINAHL and Web of Science) will be conducted. Relevant literature will also be identified from the reference lists of included studies. Two reviewers will independently screen titles and abstracts and full-texts against specified inclusion and exclusion criteria. A third reviewer will resolve disagreements if necessary. Relevant data will be extracted using a data charting form. Quantitative and qualitative summaries of extracted data will be provided.

ETHICS AND DISSEMINATION

No ethical approval is required for this study. Findings will be of benefit to researchers, clinicians and policy-makers by highlighting areas for future research and identifying ways to making ED treatment more accessible for individuals from all backgrounds. Findings will be disseminated via conferences, presentations and peer-reviewed journals.

Cultural adaptation of an integrated eating disorders prevention and healthy weight management program

BACKGROUND

Both eating disorder (ED) prevention and weight management interventions often focus on the thin ideal. Yet, many Black and Latina women do not view thinness as their body ideal. This study used focus groups to investigate the influence of race, ethnicity, and culture on appearance ideals and inform the cultural adaptation and integration of two established programs addressing EDs and weight management: the Body Project, and Healthy Weight Interventions.

METHODS

White (n = 10), Black (n = 14), and Latina (n = 6) women participated in racially and ethnically homogenous focus groups.

RESULTS

Thematic analysis identified several themes, including: (1) diverse beauty standards across groups, (2) lack of acknowledgement of racialized beauty standards in prevention and cultural appropriation, (3) culturally-specific impacts of standards, (4) harm of appearance-related comments, (5) limitations of available resources, (6) stigma/minimization of mental health, (7) barriers to inclusive programming, and (8) facilitators of inclusive programming.

CONCLUSIONS

Results suggested that current programs' emphasis on thinness limit their relevance for women of color, and perpetuate the misconception that EDs primarily affect White women. Findings highlight the need for culturally responsive prevention.

Longitudinal Stability of Disordered-Eating Symptoms From Age 12 to 40 in Black and White Women

The purpose of the current study was to test the longitudinal association between disordered eating symptoms (body dissatisfaction, drive for thinness and bulimia) in adolescence (ages 12, 14, 16, 18, 19) and adulthood (age 40) in a sample of 883 white and Black women. We also investigated moderation by race. Adolescent symptoms at each time point significantly predicted adulthood symptoms for the body dissatisfaction and drive for thinness subscales, for both Black and white women. Bulimia symptoms in adolescence predicted symptoms in adulthood; however, the effect was largely driven by white women. Although moderation was non-significant, among white women, bulimia symptoms at all adolescent time points predicted adulthood bulimia, but among Black women, only symptoms at ages 18 and 19 were predictive of adulthood bulimia. Results suggest that both Black and white women are susceptible to disordered eating and that symptoms emerging in adolescence can potentially follow women into midlife.

The need for epidemiological research on eating disorders in Africa and the Caribbean

The eating disorders field acknowledges the need to include diverse populations in research. Although global diversity has increased in epidemiologic research, there is still a significant lack of research in Africa and the Caribbean. The objectives of this article are to highlight knowledge gaps in these regions and make recommendations to improve future research. We searched the literature about the epidemiology of eating disorders in Africa and the Caribbean and provided a brief summary of research findings and measures used to identify cases. There is a large knowledge gap about the epidemiology of eating disorders across African and Caribbean nations. Knowledge about the cultural appropriateness of measurement instruments and screening tools is also lacking. Inadequate information about the epidemiology of eating disorders in Africa and the Caribbean inhibits the eating disorders research field from identifying who is affected. Further, measures and screening instruments with uncertain cultural validity inhibit the ability to understand case presentations and treatment targets. We recommend that the field advocate for the inclusion of eating disorders in larger population health research and that future research should evaluate the appropriateness of measurement instruments to capture eating disorder cases in African and Caribbean countries. PUBLIC SIGNIFICANCE: There is a lack of eating disorder research in African and Caribbean countries. The limited studies that do exist show evidence of eating disorders in African and Caribbean countries. Research is needed to develop culturally relevant measures for screening and case identification, and to calculate incidence and prevalence.

Racial/ethnic differences in anorexia and bulimia diagnoses among U.S. college students

This study examined the prevalence of anorexia nervosa (AN) and bulimia nervosa (BN) diagnoses among college students from different racial/ethnic backgrounds. Utilizing archival data from the American College Health Association - National College Health Assessment II-C (ACHA-NCHA II-C), information from 426,425 college students collected between 2015 and 2019 was examined. Binary logistic regression analyses were conducted to determine the prevalence of AN and BN diagnoses among various racial and ethnic groups. The highest odds of AN diagnosis were observed among American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) students, with odds ranging from 2.143 (compared to White students) to 3.744 (compared to Black students). White students had higher odds of AN than Black (OR = 1.748), Hispanic/Latino (OR = 1.706), and Asian (OR = 1.531) students. Biracial/Multiracial students had significantly higher odds of AN than Black (OR = 1.653), Hispanic/Latino (OR = 1.616), and Asian (OR = 1.449) students. In terms of BN diagnoses, AI/AN/NH students had the highest odds compared to all other groups, ranging from 2.149 (compared to White students) to 2.899 (compared to Hispanic/Latino students). White students had higher odds of BN than Black (OR = 1.271) and Hispanic/Latino (OR = 1.350) students. Biracial/Multiracial students also had significantly higher odds of BN than Black (OR = 1.388) and Hispanic/Latino (OR = 1.474) students. Asian students had higher odds of BN than Black (OR = 1.252) and Hispanic/Latino (OR = 1.329) students. These findings demonstrate complex patterns of AN and BN diagnoses among different racial/ethnic groups. These results highlight the need for culturally sensitive prevention and treatment plans on college campuses.

Fear of COVID-19, insomnia, and eating disorder symptoms among Iranian college students

Objective

Eating disorders (EDs), fear of COVID-19, and insomnia have all increased during the COVID-19 pandemic in Western societies. Additionally, fear of COVID-19 and sleep disturbances relate to ED symptoms in Western societies. However, it is unknown whether fear of COVID-19 and insomnia relate to ED symptoms in non-Western countries, such as Iran. Thus, this study examined the relation between fear of COVID-19, insomnia, and ED symptoms among Iranian college students. Specifically, we hypothesized that insomnia and fear of COVID-19 would each uniquely relate to ED symptoms and the interaction between insomnia and fear of COVID-19 would also associate with increased ED symptoms.

Method

College students (N =1,043) filled out measures assessing fear of COVID-19, insomnia, and ED symptoms. We ran moderation analyses using linear regression for global ED symptoms and negative binomial regressions for binge eating and purging.

Results

Fear of COVID-19 and insomnia had unique effects on global ED symptoms and binge eating. Insomnia, but not fear of COVID-19, had a unique effect on purging. No significant interaction effect was found.

Discussion

This study was the first to examine the association between fear of COVID-19 and insomnia on ED symptoms in Iran. Fear of COVID-19 and insomnia should be incorporated into novel assessments and treatments for EDs.

Reimagining eating disorder spaces: a qualitative study exploring Māori experiences of accessing treatment for eating disorders in Aotearoa New Zealand

BACKGROUND

Health, illness, and the body are conceptualized within the cultural context of a society. The values and belief systems of a society, including media portrayals, shape how health and illness present. Traditionally, Western portrayals of eating disorders have been prioritized over and above Indigenous realities. This paper explores the lived experiences of Māori with eating disorders and their whānau (family/support system) to identify the enablers and barriers to accessing specialist services for eating disorders in New Zealand.

METHOD

Kaupapa Māori research methodology was used to ensure the research supported Māori health advancement. Fifteen semi-structured interviews were completed with Māori participants including; those with an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, and binge eating disorder), and/or their whānau. Structural, descriptive, and pattern coding was undertaken within the thematic analysis. Low's spatializing culture framework was used to interpret the findings.

RESULTS

Two overarching themes identified systemic and social barriers to accessing treatment for Māori with eating disorders. The first theme, was space, that described the material culture within eating disorder settings. This theme critiqued eating disorder services, including idiosyncratic use of assessment methods, inaccessible service locations, and the limited number of beds available in specialist mental health services. The second theme, place, referred to the meaning given to social interactions created within space. Participants critiqued the privileging of non-Māori experiences, and how this makes a place and space of exclusion for Māori and their whānau in eating disorder services in New Zealand. Other barriers included shame and stigma, while enablers included family support and self-advocacy.

CONCLUSION

More education is needed for those working in the space of primary health settings about the diversity of those with eating disorders to enable them to look beyond the stereotype of what an eating disorder looks like, and to take seriously the concerns of whaiora and whānau who present with disordered eating concerns. There is also a need for thorough assessment and early referral for eating disorder treatment to ensure the benefits of early intervention are enabled for Māori. Attention given to these findings will ensure a place for Māori in specialist eating disorder services in New Zealand.

A lived experience response to the proposed diagnosis of terminal anorexia nervosa: learning from iatrogenic harm, ambivalence and enduring hope

The ethical approach to treatment non-response and treatment refusal in severe-enduring anorexia nervosa (SE-AN) is the source of significant ethical debate, particularly given the risk of death by suicide or medical complications. A recent article proposed criteria to define when anorexia nervosa (AN) can be diagnosed as 'terminal' in order to facilitate euthanasia or physician-assisted suicide (EAS), otherwise known as medical assistance in dying, for individuals who wish to be relieved of suffering and accept treatment as 'futile'. This author utilises their personal lived experience to reflect on the issues raised, including: treatment refusal, iatrogenic harm, suicidality and desire to end suffering, impact of diagnosis/prognosis, schemas, alexithymia, countertransference, ambivalence, and holding on to hope. Within debates as critical as the bioethics of involuntary treatment, end-of-life and EAS in eating disorders, it is crucial that the literature includes multiple cases and perspectives of individuals with SE-AN that represent a wide range of experiences and explores the complexity of enduring AN illness, complex beliefs, communication patterns and relational dynamics that occur in SE-AN.

Disadvantage and disordered eating in boys: Examining phenotypic and genotype × environment associations across development

Socioeconomic disadvantage may be a significant risk factor for disordered eating, particularly for individuals with underlying genetic risk. However, little to nothing is known about the impact of disadvantage on disordered eating in boys during the critical developmental risk period. Crucially, risk models developed for girls may not necessarily apply to boys, as boys show different developmental patterns of disordered eating risk (i.e., earlier activation of genetic influences during adrenarche, an early stage of puberty). This is the first study to examine phenotypic and Genotype × Environment (G × E) effects of disadvantage in boys. Analyses examined 3,484 male twins ages 8-17 (Mage = 12.27, SD = 2.96) from the Michigan State University Twin Registry. Disordered eating (e.g., body dissatisfaction, binge eating) was measured using the parent-report Michigan Twins Project Eating Disorder Survey. Neighborhood disadvantage was measured using a census-tract level Area Deprivation Index, and family socioeconomic status was determined from parental income and education. Adrenarche status was determined using multiple indicators, including age and Pubertal Development Scale scores. G × E models suggested that genetic influences on disordered eating were activated earlier for boys experiencing familial or neighborhood disadvantage, with substantial genetic influences in early adrenarche, when genetic influences were low in more advantaged boys. Phenotypically, both neighborhood and familial disadvantage were associated with greater disordered eating for boys in late adrenarche, which could indicate a lasting impact of earlier activation of genetic influences on later risk. Results highlight disadvantage as a novel risk factor for disordered eating in boys, particularly those with genetic vulnerabilities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

An investigation of associations between parenting and binge eating across pubertal development in pre-adolescent and adolescent female participants

OBJECTIVE

Puberty is a period of increased risk for the development of binge eating in female adolescents. Although developmental changes in autonomy-seeking behaviors and body weight and shape may influence both parenting styles and binge eating during puberty, studies have yet to examine how parenting practices may be differentially associated with youth outcomes depending on developmental stage. The current study examines whether interactions between puberty and parenting are associated with higher levels of binge-eating symptoms during/after puberty in female youth.

METHODS

Analyses used cross-sectional data from a previous study of disordered eating and puberty in 999 female youth (ages 8-16) and their parents from the Michigan State University Twin Registry. Youth self-reported binge eating, pubertal development, and perceived parental care and overprotection. Both parents and youth reported on parent-child conflict. Mixed linear models were used to examine whether pubertal development moderates the strength of associations between parenting (parent-child conflict, parental care, and parental overprotection) and offspring binge eating.

RESULTS

Although higher levels of parental overprotection and conflict, and lower levels of parental care were all significantly associated with binge eating, none of the associations were significantly moderated by pubertal development or age.

DISCUSSION

The quality of the parent-child relationship is significantly associated with binge eating in female youth regardless of developmental stage, highlighting the need for targeting harmful parenting strategies during adolescent eating disorder intervention.

PUBLIC SIGNIFICANCE

This is the first study to examine whether parenting/binge-eating associations in female participants differ across pubertal development. In a large population-based sample, we found lower parental care, higher parent-child conflict, and higher parental overprotection were all associated with higher levels of binge eating. Notably, associations did not differ across pubertal stage or age, suggesting that parenting is significantly associated with binge eating, regardless of developmental stage.

Conceptualizing eating disorder recovery research: Current perspectives and future research directions

BACKGROUND

How we research eating disorder (ED) recovery impacts what we know (perceive as fact) about it. Traditionally, research has focused more on the "what" of recovery (e.g., establishing criteria for recovery, reaching consensus definitions) than the "how" of recovery research (e.g., type of methodologies, triangulation of perspectives). In this paper we aim to provide an overview of the ED field's current perspectives on recovery, discuss how our methodologies shape what is known about recovery, and suggest a broadening of our methodological "toolkits" in order to form a more complete picture of recovery. BODY: This paper examines commonly used methodologies in research, and explores how incorporating different perspectives can add to our understanding of the recovery process. To do this, we (1) provide an overview of commonly used methodologies (quantitative, qualitative), (2) consider their benefits and limitations, (3) explore newer approaches, including mixed-methods, creative methods (e.g., Photovoice, digital storytelling), and multi-methods (e.g., quantitative, qualitative, creative methods, psycho/physiological, behavioral, laboratory, online observations), and (4) suggest that broadening our methodological "toolkits" could spur more nuanced and specific insights about ED recoveries. We propose a potential future research model that would ideally have a multi-methods design, incorporate different perspectives (e.g., expanding recruitment of diverse participants, including supportive others, in study co-creation), and a longitudinal course (e.g., capturing cognitive and emotional recovery, which often comes after physical). In this way, we hope to move the field towards different, more comprehensive, perspectives on ED recovery.

CONCLUSION

Our current perspectives on studying ED recovery leave critical gaps in our knowledge about the process. The traditional research methodologies impact our conceptualization of recovery definitions, and in turn limit our understanding of the phenomenon. We suggest that we expand our range of methodologies, perspectives, and timeframes in research, in order to form a more complete picture of what is possible in recovery; the multiple aspects of an individual's life that can improve, the greater number of people who can recover than previously believed, and the reaffirmation of hope that, even after decades, individuals can begin, and successfully continue, their ED recovery process.

Interactions between emotions and eating behaviors: Main issues, neuroimaging contributions, and innovative preventive or corrective strategies

Emotional eating is commonly defined as the tendency to (over)eat in response to emotion. Insofar as it involves the (over)consumption of high-calorie palatable foods, emotional eating is a maladaptive behavior that can lead to eating disorders, and ultimately to metabolic disorders and obesity. Emotional eating is associated with eating disorder subtypes and with abnormalities in emotion processing at a behavioral level. However, not enough is known about the neural pathways involved in both emotion processing and food intake. In this review, we provide an overview of recent neuroimaging studies, highlighting the brain correlates between emotions and eating behavior that may be involved in emotional eating. Interaction between neural and neuro-endocrine pathways (HPA axis) may be involved. In addition to behavioral interventions, there is a need for a holistic approach encompassing both neural and physiological levels to prevent emotional eating. Based on recent imaging, this review indicates that more attention should be paid to prefrontal areas, the insular and orbitofrontal cortices, and reward pathways, in addition to regions that play a major role in both the cognitive control of emotions and eating behavior. Identifying these brain regions could allow for neuromodulation interventions, including neurofeedback training, which deserves further investigation.

Unheard voices: The impact of the COVID-19 pandemic on disordered eating in people with marginalized identities: Commentary on Devoe et al. (2022), Linardon et al. (2022) and Schneider et al. (2022)

Reviews by Devoe et al. (2022), Linardon et al. (2022), and Schneider et al. (2022) illustrate the profound impact the COVID-19 pandemic has had on people with eating disorders (EDs) or disordered eating (DE) and their families. However, there is a dearth of research on how the pandemic has affected individuals with marginalized identities, who have been historically underrepresented in ED/DE research. The few studies conducted to date suggest that people with marginalized identities, including people of color, LGBTQ + people, women, and people experiencing socioeconomic disadvantage, may have had even greater increases in EDs/DE than people without marginalized identities. In this Commentary, I discuss who is missing from research on EDs/DE during the COVID-19 pandemic, strategies for breaking down barriers to participation in research for diverse groups, and the implications of existing research findings for people with marginalized identities. Improved measurement of salient aspects of participants' identities and increased recruitment and retention of participants from diverse backgrounds is necessary to more fully understand the impact of the COVID-19 pandemic on all people affected by EDs and DE. Concurrently, increased access to affordable and culturally sensitive care is urgently required to meet the extensive treatment needs already documented.

Eating Disorder Examination-Questionnaire: Evaluating factor structures and establishing measurement invariance with Asian/Hawaiian/Pacific Islander, Black, and White American college men

OBJECTIVE

This study evaluated the factor structure and invariance of the Eating Disorder Examination-Questionnaire (EDE-Q) in a sample of Asian/Hawaiian/Pacific Islander (n = 163), Black (n = 155), and White (n = 367) American university men.

METHOD

Twelve different EDE-Q factor structures reported in the literature were evaluated using multi-group confirmatory factor analyses, and measurement invariance assessed.

RESULTS

A respecified four-factor structure proposed by Parker et al. (2016) showed superior fit and was invariant across groups. Significant differences emerged across all latent factors, with small to medium effects. Asian/Hawaiian/Pacific Islander men reported significantly higher scores on factors assessing Appearance Concern, Overvaluation of Shape/Weight, and Eating Concerns, and were more likely to endorse regular objective binge eating (OBE) and fasting episodes than their Black and White peers. Both White and Asian/Hawaiian/Pacific Islander men reported greater dietary restraint than Black men. Among this sample, frequencies of regular compensatory exercise ranged from 10% to 16%, fasting 6% to 14%, and OBEs 1% to 10%.

DISCUSSION

Results provide further support for the use of alternate EDE-Q factor structures, especially among non-White men. In this study, Asian/Hawaiian/Pacific Islander men reported the highest levels of ED psychopathology relative to White and Black men, indicating they might be particularly vulnerable to EDs.

PUBLIC SIGNIFICANCE

This study failed to find support for using the original Eating Disorder Examination-Questionnaire four-factor structure to detect disordered eating in Asian, Black, and White American college men. An alternate model proposed by Parker et al. in 2016 may be more appropriate. Asian men also reported the highest levels of eating psychopathology relative to their peers, suggesting they may be at high risk for developing eating disorders.

Reporting racial and ethnic diversity in eating disorder research over the past 20 years

OBJECTIVE

Recent public awareness of racial and ethnic disparities has again brought to light issues of diversity, equity, and inclusion in the eating disorders field. However, empirical information on racial and ethnic representation in eating disorders research is limited, making it difficult to understand where improvements are needed.

METHOD

This study reviewed all studies including human participants published in the International Journal of Eating Disorders in 2000, 2010, and 2020. Differences in likelihood of reporting race and ethnicity were calculated based on study year, location, and diagnostic categories.

RESULTS

Out of 377 manuscripts, 45.2% reported information on the race and ethnicity of study participants. Studies conducted in the United States were more likely to report (128/173), and those conducted in Europe were less likely to report (5/61) on race and ethnicity than those conducted outside of those regions. Rates of reporting increased from 2000 to 2020. White participants made up approximately 70% of the samples that reported race and ethnicity data. Hispanic participants made up approximately 10% of samples reporting race and ethnicity. Participants from all other races and ethnicities made up less than 5% each.

DISCUSSION

Although rates of reporting race and ethnicity increased over time, most participants were White. Rates of reporting also differed by the geographical region, which may reflect variability in how information on race and ethnicity is collected across countries. More attention toward capturing the cultural background of research participants and more inclusivity in research are needed in the eating disorders field.

A mixed-studies systematic review of the experiences of body image, disordered eating, and eating disorders during the COVID-19 pandemic

OBJECTIVES

This systematic review assessed the influence of the COVID-19 pandemic and associated restrictions on body image, disordered eating (DE), and eating disorder outcomes.

METHODS

After registration on PROSPERO, a search was conducted for papers published between December 1, 2019 and August 1, 2021, using the databases PsycINFO, PsycARTICLES, CINAHL Plus, AMED, MEDLINE, ERIC, EMBASE, Wiley, and ProQuest (dissertations and theses).

RESULTS

Data from 75 qualitative, quantitative, and mixed-methods studies were synthesized using a convergent integrated approach and presented narratively within four themes: (1) disruptions due to the COVID-19 pandemic; (2) variability in the improvement or exacerbation of symptoms; (3) factors associated with body image and DE outcomes; (4) unique challenges for marginalized and underrepresented groups. Disruptions due to the pandemic included social and functional restrictions. Although most studies reported a worsening of concerns, some participants also reported symptom improvement or no change as a result of the pandemic. Factors associated with worse outcomes included psychological, individual, social, and eating disorder-related variables. Individuals identifying as LGBTQ+ reported unique concerns during COVID-19.

DISCUSSION

There is large variability in individuals' responses to COVID-19 and limited research exploring the effect of the pandemic on body image, DE, and eating disorder outcomes using longitudinal and experimental study designs. In addition, further research is required to investigate the effect of the COVID-19 pandemic on body image and eating concerns among minoritized, racialized, underrepresented, or otherwise marginalized participants. Based on the findings of this review, we make recommendations for individuals, researchers, clinicians, and public health messaging.

PUBLIC SIGNIFICANCE

This review of 75 studies highlights the widespread negative impacts that the COVID-19 pandemic and associated restrictions have had on body image and disordered eating outcomes. It also identifies considerable variations in both the improvement and exacerbation of said outcomes that individuals, researchers, clinicians, and other public health professionals should be mindful of if we are to ensure that vulnerable people get the tailored support they require.

"Are people thinking I'm a vector…because I'm fat?": Cisgender experiences of body, eating, and identity during COVID-19

While a range of studies have shown the negative impact of COVID-19 on disordered eating and body image, few have engaged with how identity and social context interact with these domains. The current study used inductive codebook thematic analysis to understand experiences of body and eating during the pandemic among a diverse (sub)clinical sample of individuals with self-reported disordered eating. We interviewed 31 cisgender participants (18/31 Black Indigenous People of Color (BIPOC), 24/31 women) with a history of disordered eating (diagnosed and undiagnosed). Five themes were identified: Body Surveillance and Dissatisfaction, Movement and Intake Fixation, Food Scarcity and Resource Concerns, Changes in Visibility of Body and Eating, and Bodies Are Vulnerable. We examined the extent to which themes pertained to certain identities over others. Notably, BIPOC, large-bodied, queer participants more commonly spoke to body vulnerability than White, small/medium-bodied, straight participants. BIPOC and large-bodied participants also particularly spoke to feeling relief from discrimination as social distancing and mask wearing reduced their public visibility. Participants related these themes to changed body and eating experiences that spanned distress and resilience. Our analysis offers insight into multifaceted and contextual impacts of COVID-19 on experiences of body, eating, and identity.

Affect Dysregulation in Context: Implications and Future Directions of Experience Sampling Research on Affect Regulation Models of Loss of Control Eating

Loss of control eating is a core, transdiagnostic eating disorder symptom associated with psychological distress, functional impairment, and reduced quality of life. However, the factors that contribute to persistent loss of control eating despite negative consequences are not fully understood. Understanding the mechanisms that maintain loss of control eating is crucial to advance treatments that interrupt these processes. Affect regulation models of loss of control eating hypothesize that negative emotions trigger loss of control eating, and that loss of control eating is negatively reinforced because it temporarily decreases negative affect. Several variations on this basic affect regulation model have been proposed, including theories suggesting that negative affect decreases during loss of control eating rather than afterwards (escape theory), and that loss of control eating replaces one negative emotion with another that is less aversive (trade-off theory). Experience sampling designs that measure negative affect and eating behavior multiple times per day are optimally suited to examining the nuanced predictions of these affect regulation models in people's everyday lives. This paper critically reviews experience sampling studies examining associations between negative affect and loss of control eating, and discusses the implications for different affect regulation models of loss of control eating. The review concludes by proposing an expanded affect-focused model of loss of control eating that incorporates trait-level individual differences and momentary biological and environmental variables to guide future research. Clinical implications and recommendations are discussed.